Ivor Lewis procedure

Last revised by Lilit Ganjalyan on 16 Jan 2023

Ivor Lewis procedure (also known as a gastric pull-up) is a type of esophagectomy, an upper gastrointestinal tract operation performed for mid and distal esophageal pathology, usually esophageal cancer.

Due to the necessity of removing a significant length of the esophagus, the stomach is "pulled up" into the thoracic cavity. The resulting appearances can be striking on chest x-ray, with an appearance mimicking achalasia.

  • laparotomy
    • stomach and esophagus mobilized
    • "gastric tube" may be formed
    • abdominal lymphadenectomy
    • possible pyloroplasty/pyloromyotomy (not practised by all surgeons)
  • right thoracotomy
    • esophagus and adjacent tissue removed en bloc
    • mediastinal lymphadenectomy
    • stomach (or gastric tube) pulled into the chest and anastomosed with the more proximal esophagus

The conduit is usually paravertebral but may be substernal or right paratracheal.

Potential advantages over the McKeown procedure are lower rates of stricture, leak, recurrent laryngeal nerve palsy, and aspiration 2.

  • tubular paramediastinal structure
    • extending from cardiophrenic angle to thoracic inlet
    • may have air-fluid level
  • evidence of right-sided thoracotomy 
    • rib deformity
    • suture material or mediastinal surgical clips
  • absent stomach bubble

The distinguished Welsh surgeon Ivor Lewis (1895-1982) first described his procedure in the Hunterian Oration at the Royal College of Surgeons in 1946 3,5.

The imaging differential diagnosis includes:

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